Without supports for direct home care workers, older adults are at risk of unwanted nursing home admissions

The need for direct home care workers — health professionals who work with individuals in their homes — is growing, and demand outpaces supply. In the US, states can use American Rescue Plan funds to expand their direct care workforce, but this funding expires in 2025. Without a sustainable plan to recruit and retain direct care workers, aging Baby Boomers are at risk of unwanted nursing home admissions.

Direct care workers include personal care aides, home health aides, and certified nursing assistants (CNAs). All provide assistance with activities of daily living — tasks like feeding or bathing oneself. Home health aides and CNAs perform additional tasks, including monitoring vital signs, transferring individuals from a bed to a chair, and wound dressing. Depending on the state, they may assist with medication administration. All of these activities facilitate independent living in one’s home or community, the settings where the majority of older adults prefer to receive long-term care. Demand for the services of direct care workers continues to grow.

Despite their critical role in independent living, direct care workers generally receive low salaries and are undervalued by society. In 2021, the median pay for a home health aide or personal care aide was $14.15/hour ($29,430/year). It was only slightly higher for nursing assistants. Salaries meeting the federal minimum wage were not guaranteed until 2015. Low salaries, along with limited opportunities for career advancement and the potential for on-the-job injuries contribute to high rates of turnover. Forty to sixty percent of direct care workers leave their jobs annually. The work is important, but difficult and inadequately compensated.

In recognition of these issues, the 2021 American Rescue Plan provided states with Medicaid funding to “enhance, expand, or strengthen” their home and community-based care services, including those provided by direct care workers. Funding for direct care workers is intended to support recruitment and retention of staff and can be used to increase worker compensation. States have flexibility in how they use the funds — example strategies include investments in loan repayment, tuition assistance, hiring bonuses, career ladder development, and enhanced training. The ability to use these funds was recently extend to 2025, but there are no long-term plans to sustain improvements in infrastructure and wages.

To meet the growing demand for the services of direct care workers, long-term funding is needed to identify and sustain effective strategies targeting their recruitment and retention. Economic models suggest that increasing compensation of direct care workers to state-specific living wages would improve both recruitment and retention. Participants in loan repayment programs targeted to health care professions report high satisfaction with the programs, but data limitations make it difficult to draw conclusions about their effect on recruitment. A comprehensive approach that focuses on compensation, career advancement, improved working conditions and recognition of the value of direct care workers is likely needed.  Where possible, states should monitor the recruitment and retention approaches used and evaluate whether they have had the intended effect on the direct care workforce. Best practices identified by one state can inform other states’ resource allocation decisions.

The population continues to age. By 2035, more than 1 in 10 United States residents will be age 75 or older. The need to secure resources and identify strategies to allow individuals to receive care at home when desired while supporting the workforce that makes this possible is greater than ever.

Research for this piece was supported by Arnold Ventures.

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